CMN 552
Module 1
Primary Study Guide
University of South Alabama
, CMN552 zx
Module1PrimaryStudyGuide(MoodDisorders) x
z x
z zx zx zx zx
Carlat Chapter 23 zx zx
Asking About the Symptoms of Depression
zx zx zx zx zx
>A related difficulty is distinguishing true-positive from false-
zx zx zx zx zx zx zx
positive responses to questions about symptoms. Most
zx zx zx zx zx zx W
people experience some of the symptoms of major depr e zx zx zx zx zx zx zx zx zx
ssion to some degree at some time. Establishing that your patient has symptoms severe enough to meet DSM-
zx zx zx zx zx zx zx zx zx z x zx zx zx zx zx zx z x
5 criteria takes creativity, persistence, and experience.
zx zx zx zx zx zx
● Establish that the symptom is truly a change from baseline. zx WS zx zx zx zx zx zx zx
● Establish that the symptom has occurred almost every day for 2 weeks. zx WS zx zx zx zx WS zx zx zx zx
>It’s useful to remind patients that you are asking about a specific period.
zx zx zx zx zx zx zx zx zx zx zx zx
>Think back carefully: Have you felt depressed pretty much every day over the past 2 weeks?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
● Try not to ask leading questions. An example of a leading question is “Has your depression made it hard for yo u
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx WS zx zx zx
to concentrate?” This implies that decreased concentration would be expected, and a suggestible or malinge ring
zx zx zx zx WS zx zx zx zx zx zx zx zx zx zx
patient might answer with a false “yes.” An example of a nonleading question would be “Do you think you r con
zx WS zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x
centration has been better or worse than normal over the past 2weeks?” Of course, you can substitute a ny
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
of the NVSs for “concentration” in this template.
zx zx zx zx zx zx zx
Screening Questions zx
● Are you depressed? zx zx
● How has your mood been recently? zx zx zx zx zx
● Have you ever felt very down or depressed, so depressed that your whole life was affected by it for at least
zx zx zx WS zx zx zx zx zx zx WS zx zx zx zx zx zx zx zx zx W
2 weeks S zx
SIGECAPS Questions zx
Sleep disorder (either increased or decreased) Int
zx zx zx zx zx zx
erest deficit (anhedonia) Guilt (worthlessness, h
zx WS zx WS zx
opelessness, regret) zx
Energy deficit Concentrati o zx z x zx
ndeficit
x
z
Appetite disorder (either decreased orincreased)
zx zx zx zx x
z
Psychomotor retardation or agitation Suicida lity zx zx zx z x zx
● For dysthymic disorder, two of the six starred symptoms must be present.
zx WS zx zx zx zx zx zx zx zx zx
● Recommended time: 1 minute if the screen is negative; 5 minutes if the screen is positive. zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Sleep disorder zx
Have you been sleeping normally? (A good initial screening question for a sleep problem.)
zx zx zx zx zx zx zx zx zx zx zx zx zx
What has your sleep pattern been like lately? (Depending on the adequacy of your patient’s response to this question, you ma
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
y or may not need to follow up with the following questions.)
zx zx zx zx zx zx zx zx zx zx zx
Whattime do you lie down to fall asleep? What time do you actually fall asleep?(To diagnose difficulty falling asleep.)
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Doyou sleep through the night or wake up often during the night?(To diagnose frequent awakenings.)
x
z zx zx zx zx zx zx zx zx zx zx zx zx zx zx
,What time do you usually wake up in the morning? Do you generally feel rested when you wake up?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Do you feel more or less depressed when you wake up? How does your mood change as the day goes on?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
(To diagnose early morning awakening and diurnal variation in mood.)
zx zx zx zx zx zx zx zx zx
>Interest deficit (anhedonia): Anhedonia is a surprisingly difficult symptom to ascertain. Obviously, no patient will zx WS zx zx zx zx zx zx zx zx zx zx zx zx
come right out and say, “Doctor, I’ve been really anhedonic lately.” You will more likely hear words like, “I’m bored a
zx zx WS WS zx zx zx zx zx zx zx zx zx zx zx zx zx WS zx zx zx
ll
the time,” “I have no motivation,” or “I don’t care about anything.” One problem is that patients may not understand wha
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx WS zx
t
we mean if we ask, “Can you describe your interest level?” or “Have you been taking pleasure in things?” A pati ent may
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
z only associate pleasure with extraordinary experiences, such as going on vacation, or she may say she has b een taking
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x
an interest in things when, in fact, her level of interest has decreased markedly since the onset of depressi on. Because o
zx WS zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x
f these potential pitfalls, it’s important to be specific in your questioning.
zx zx zx zx zx WS zx zx zx zx zx
>Before you felt really sad, what sorts of things would you do for fun or relaxation? zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
What sorts of hobbies did you have? Did you read? Did you play sports or follow the sports teams? Did you go out to the mo
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
vies? Did you go out with friends? zx zx zx zx zx zx
This establishes a baseline against which to compare the depressed period. You can then go on to ask about how th
WS zx zx zx WS zx zx zx zx zx zx zx zx zx zx zx zx WS zx zx
e depression has affected the patient’s activities:
zx zx zx zx zx zx
Since you have felt depressed, have you noticed thatyou’ve been any less interested in these pursuits? Have you found t
zx zx zx WS zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
hat you’ve been able to enjoy the things you used to enjoy? H
zx zx zx zx zx zx zx zx zx zx zx z x
ave you given up doing anything that you normally like to do?
zx zx zx zx zx zx zx zx zx zx zx
*If the person you are evaluating is already on an antidepressant, particularly if this is a selective serotonin reuptake inhi bito
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx
r (SSRI), he may seem to have anhedonia, whereas he may actually have “apathy syndrome” secondary to the antide
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx
pressant. This occurs in up to 20% to 30% of patients on newer antidepressants and may be caused by low ered level
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx zx
s of brain dopamine.
zx zx zx
>Guilt, worthlessness, hopelessness: Here, you want to understand how negatively the patient feels about himself.
zx zx zx zx zx zx zx zx zx zx zx WS zx WS
Starting with questions that assess the patient’s self-worth often works well:
WS WS WS WS WS WS WS WS WS WS
How have you been feeling about yourself, in terms of self-esteem, since you’ve been depressed?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Do you feel that you are essentially a good person, or do you have your doubts? Have you felt especially critical of
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
yo z
urself lately? These questions touch specifically on the theme of hopelessness: How do you see your future?
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x
Do you have hope that things will get better, or does it look pretty bleak?Do you feel helpless to change your situation?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
*Have you felt guilty or regretful about things you’ve done or haven’t done? Like not being productive, not reaching your potential, b
zx zx zx zx zx zx WS zx zx zx zx WS zx zx zx zx zx zx zx zx zx
eing a burden? zx zx
Energy deficit: Begin with a screening question. zx zx zx zx zx zx
Howhas your energy level been over the past couple of weeks?--If the patient answers “Lousy,”
zx zx zx zx zx zx zx zx zx zx zx zx zx WS WS
z x
Is this a change for you? Did you feel significantly more energetic before your depression?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
*Because medical illness can cause anergia in the absence of depression, you may be misled about the source of th
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e loss of energy, particularly when dealing with patients with chronic medical illnesses or geriatric
zx zx zx pati zx zx zx zx zx zx zx zx zx zx zx
ents. In such cases, asking about the energy pattern throughout the day is helpful. Patients with medical illnesses are at
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
their most energetic when they wake up and then feel worse as the day progresses, whereas depressed
zx WS zx zx zx zx zx zx zx zx zx zx zx zx zx zx
patients often wake up feeling low and anergic and feel better later in the day. Concentratio zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
n deficit.zx
Have you been able to focus on things well? How has your concentration been?(These general questions are
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx WS
somet zx
imes sufficient for screening purposes.) Have you felt more absentminded than usual? Have you noticed any change s i
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx zx
n your memory?(These get at the pseudodementia sometimes seen in depression.) Have you had problems maki ng de
zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx zx
cisions? Sometimes, the first sign of concentration problems is difficulty making basic decisions such as
zx zx zx zx zx zx zx zx zx zx zx zx zx zx W
“What zx
should I make for dinner?” or “Should I go out tonight or not?”If you were to sit down with a newspaper in front of
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx WS zx zx zx zx zx zx
, yo u, w
zx zx
ould you be able to read an entire article from start to finish without losing your concentration, or do you have to
zx zx zx zx zx zx zx zx zx zx WS zx zx zx zx zx zx zx zx zx zx
Module 1
Primary Study Guide
University of South Alabama
, CMN552 zx
Module1PrimaryStudyGuide(MoodDisorders) x
z x
z zx zx zx zx
Carlat Chapter 23 zx zx
Asking About the Symptoms of Depression
zx zx zx zx zx
>A related difficulty is distinguishing true-positive from false-
zx zx zx zx zx zx zx
positive responses to questions about symptoms. Most
zx zx zx zx zx zx W
people experience some of the symptoms of major depr e zx zx zx zx zx zx zx zx zx
ssion to some degree at some time. Establishing that your patient has symptoms severe enough to meet DSM-
zx zx zx zx zx zx zx zx zx z x zx zx zx zx zx zx z x
5 criteria takes creativity, persistence, and experience.
zx zx zx zx zx zx
● Establish that the symptom is truly a change from baseline. zx WS zx zx zx zx zx zx zx
● Establish that the symptom has occurred almost every day for 2 weeks. zx WS zx zx zx zx WS zx zx zx zx
>It’s useful to remind patients that you are asking about a specific period.
zx zx zx zx zx zx zx zx zx zx zx zx
>Think back carefully: Have you felt depressed pretty much every day over the past 2 weeks?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
● Try not to ask leading questions. An example of a leading question is “Has your depression made it hard for yo u
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx WS zx zx zx
to concentrate?” This implies that decreased concentration would be expected, and a suggestible or malinge ring
zx zx zx zx WS zx zx zx zx zx zx zx zx zx zx
patient might answer with a false “yes.” An example of a nonleading question would be “Do you think you r con
zx WS zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x
centration has been better or worse than normal over the past 2weeks?” Of course, you can substitute a ny
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
of the NVSs for “concentration” in this template.
zx zx zx zx zx zx zx
Screening Questions zx
● Are you depressed? zx zx
● How has your mood been recently? zx zx zx zx zx
● Have you ever felt very down or depressed, so depressed that your whole life was affected by it for at least
zx zx zx WS zx zx zx zx zx zx WS zx zx zx zx zx zx zx zx zx W
2 weeks S zx
SIGECAPS Questions zx
Sleep disorder (either increased or decreased) Int
zx zx zx zx zx zx
erest deficit (anhedonia) Guilt (worthlessness, h
zx WS zx WS zx
opelessness, regret) zx
Energy deficit Concentrati o zx z x zx
ndeficit
x
z
Appetite disorder (either decreased orincreased)
zx zx zx zx x
z
Psychomotor retardation or agitation Suicida lity zx zx zx z x zx
● For dysthymic disorder, two of the six starred symptoms must be present.
zx WS zx zx zx zx zx zx zx zx zx
● Recommended time: 1 minute if the screen is negative; 5 minutes if the screen is positive. zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Sleep disorder zx
Have you been sleeping normally? (A good initial screening question for a sleep problem.)
zx zx zx zx zx zx zx zx zx zx zx zx zx
What has your sleep pattern been like lately? (Depending on the adequacy of your patient’s response to this question, you ma
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
y or may not need to follow up with the following questions.)
zx zx zx zx zx zx zx zx zx zx zx
Whattime do you lie down to fall asleep? What time do you actually fall asleep?(To diagnose difficulty falling asleep.)
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Doyou sleep through the night or wake up often during the night?(To diagnose frequent awakenings.)
x
z zx zx zx zx zx zx zx zx zx zx zx zx zx zx
,What time do you usually wake up in the morning? Do you generally feel rested when you wake up?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Do you feel more or less depressed when you wake up? How does your mood change as the day goes on?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
(To diagnose early morning awakening and diurnal variation in mood.)
zx zx zx zx zx zx zx zx zx
>Interest deficit (anhedonia): Anhedonia is a surprisingly difficult symptom to ascertain. Obviously, no patient will zx WS zx zx zx zx zx zx zx zx zx zx zx zx
come right out and say, “Doctor, I’ve been really anhedonic lately.” You will more likely hear words like, “I’m bored a
zx zx WS WS zx zx zx zx zx zx zx zx zx zx zx zx zx WS zx zx zx
ll
the time,” “I have no motivation,” or “I don’t care about anything.” One problem is that patients may not understand wha
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx WS zx
t
we mean if we ask, “Can you describe your interest level?” or “Have you been taking pleasure in things?” A pati ent may
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
z only associate pleasure with extraordinary experiences, such as going on vacation, or she may say she has b een taking
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x
an interest in things when, in fact, her level of interest has decreased markedly since the onset of depressi on. Because o
zx WS zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x
f these potential pitfalls, it’s important to be specific in your questioning.
zx zx zx zx zx WS zx zx zx zx zx
>Before you felt really sad, what sorts of things would you do for fun or relaxation? zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
What sorts of hobbies did you have? Did you read? Did you play sports or follow the sports teams? Did you go out to the mo
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
vies? Did you go out with friends? zx zx zx zx zx zx
This establishes a baseline against which to compare the depressed period. You can then go on to ask about how th
WS zx zx zx WS zx zx zx zx zx zx zx zx zx zx zx zx WS zx zx
e depression has affected the patient’s activities:
zx zx zx zx zx zx
Since you have felt depressed, have you noticed thatyou’ve been any less interested in these pursuits? Have you found t
zx zx zx WS zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
hat you’ve been able to enjoy the things you used to enjoy? H
zx zx zx zx zx zx zx zx zx zx zx z x
ave you given up doing anything that you normally like to do?
zx zx zx zx zx zx zx zx zx zx zx
*If the person you are evaluating is already on an antidepressant, particularly if this is a selective serotonin reuptake inhi bito
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx
r (SSRI), he may seem to have anhedonia, whereas he may actually have “apathy syndrome” secondary to the antide
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx
pressant. This occurs in up to 20% to 30% of patients on newer antidepressants and may be caused by low ered level
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx zx
s of brain dopamine.
zx zx zx
>Guilt, worthlessness, hopelessness: Here, you want to understand how negatively the patient feels about himself.
zx zx zx zx zx zx zx zx zx zx zx WS zx WS
Starting with questions that assess the patient’s self-worth often works well:
WS WS WS WS WS WS WS WS WS WS
How have you been feeling about yourself, in terms of self-esteem, since you’ve been depressed?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
Do you feel that you are essentially a good person, or do you have your doubts? Have you felt especially critical of
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
yo z
urself lately? These questions touch specifically on the theme of hopelessness: How do you see your future?
x zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x
Do you have hope that things will get better, or does it look pretty bleak?Do you feel helpless to change your situation?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
*Have you felt guilty or regretful about things you’ve done or haven’t done? Like not being productive, not reaching your potential, b
zx zx zx zx zx zx WS zx zx zx zx WS zx zx zx zx zx zx zx zx zx
eing a burden? zx zx
Energy deficit: Begin with a screening question. zx zx zx zx zx zx
Howhas your energy level been over the past couple of weeks?--If the patient answers “Lousy,”
zx zx zx zx zx zx zx zx zx zx zx zx zx WS WS
z x
Is this a change for you? Did you feel significantly more energetic before your depression?
zx zx zx zx zx zx zx zx zx zx zx zx zx zx
*Because medical illness can cause anergia in the absence of depression, you may be misled about the source of th
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
e loss of energy, particularly when dealing with patients with chronic medical illnesses or geriatric
zx zx zx pati zx zx zx zx zx zx zx zx zx zx zx
ents. In such cases, asking about the energy pattern throughout the day is helpful. Patients with medical illnesses are at
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
their most energetic when they wake up and then feel worse as the day progresses, whereas depressed
zx WS zx zx zx zx zx zx zx zx zx zx zx zx zx zx
patients often wake up feeling low and anergic and feel better later in the day. Concentratio zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx
n deficit.zx
Have you been able to focus on things well? How has your concentration been?(These general questions are
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx WS
somet zx
imes sufficient for screening purposes.) Have you felt more absentminded than usual? Have you noticed any change s i
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx zx
n your memory?(These get at the pseudodementia sometimes seen in depression.) Have you had problems maki ng de
zx zx zx zx zx zx zx zx zx zx zx zx zx zx z x zx zx
cisions? Sometimes, the first sign of concentration problems is difficulty making basic decisions such as
zx zx zx zx zx zx zx zx zx zx zx zx zx zx W
“What zx
should I make for dinner?” or “Should I go out tonight or not?”If you were to sit down with a newspaper in front of
zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx zx WS zx zx zx zx zx zx
, yo u, w
zx zx
ould you be able to read an entire article from start to finish without losing your concentration, or do you have to
zx zx zx zx zx zx zx zx zx zx WS zx zx zx zx zx zx zx zx zx zx
